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SE21  January,  1916 

A  SURVEY  OF  THE  ACTIVITIES  OF 

MUNICIPAL  HEALTH  DEPARTMENTS 

IN  THE  UNITED  STATES 

BY 

FRANZ  SCHNEIDER,  JR. 

SANITARIAN 

DEPARTMENT  OF  SURVEYS  AND  EXHIBITS 
RUSSELL  SAGE  FOUNDATION 


Department  of  Surveys  and  Exhibits 

Russell  Sage  Foundation 
130  East  Twenty-second  Street,  New  York  City 


Price  20  Cents 


.   ■ 


SE21 


January,  1916 


A  SURVEY  OF  THE   ACTIVITIES  OF 

MUNICIPAL  HEALTH  DEPARTMENTS 

IN  THE  UNITED  STATES 


BY 


FRANZ  SCHNEIDER,  JR. 


SANITARIAN 


DEPARTMENT  OF  SURVEYS  AND  EXHIBITS 
RUSSELL  SAGE  FOUNDATION 


Department  of  Surveys  and  Exhibits 

Russell  Sage  Foundation 
130  East  Twenty-second  Street,  New  York  City 


A  SURVEY  OF  THE  ACTIVITIES  OF  MUNICIPAL 

HEALTH  DEPARTMENTS  IN  THE 

UNITED  STATES* 

The  purpose  of  this  investigation  was  to  obtain  an  approximate 
idea  of  the  status  of  health  department  work  in  the  United 
States ;  to  examine  the  departments'  programs  and  their  financial 
resources,  and  to  discover  how  great  or  small  an  advantage  they 
were  taking  of  their  existing  opportunities.  Such  an  exposition 
of  the  condition  of  our  local  public  health  work  should  aid  public 
health  officials  to  secure  increased  appropriations  and  should 
serve  as  a  basis  for  future  measurements  of  public  health  progress. 

In  scope  the  investigation  was  limited  to  cities  having  a  popu- 
lation of  25,000  and  over  according  to  the  census  of  1910,  and  to 
twelve  phases  of  work  chosen  as  of  special  importance  and  in- 
terest. The  location  of  the  cities,  of  which  there  were  227,  is 
shown  in  Figure  1 ;  their  distribution  by  state  and  group  of 
states  is  given  in  Table  1. 

The  investigation  was  carried  on  entirely  by  mail.  On 
August  1,  191 3,  letters  were  addressed  to  the  health  officers  of  the 
cities,  requesting  copies  of  their  last  two  annual  reports,  their 
codes,  and  their  financial  statements.  These  letters  also  en- 
closed a  questionaire  covering  the  twelve  subjects  of  inquiry; 
namely,  appropriation  (two  questions),  infant  hygiene  work, 
medical  inspection  of  school  children,  laboratory  service,  health 
education  and  publicity,  control  of  venereal  diseases,  housing 
regulation,  dispensary  service,  tuberculosis  work,  industrial 
hygiene,  and  the  number  of  privies.  About  one  third  of  the  de- 
partments answered  this  first  letter;  another  third  a  second 
letter  sent  out  three  weeks  after  the  first;  and  another  fifth  a 
third  letter  sent  out  a  month  after  the  second.     Letters  addressed 

*  This  paper  was  read,  in  preliminary  form,  before  the  Colorado  Springs 
meeting  of  the  American  Public  Health  Association.  In  its  present,  final, 
form  it  is  reprinted  from  the  American  Journal  of  Public  Health;  Vol.  VI, 
No.  1;  January,  1916. 

3 


ACTIVITIES   OF  MUNICIPAL   HEALTH  DEPARTMENTS   IN   U.    S. 

to  mayors  and  chambers  of  commerce  brought  in  replies  from  23 
more  cities,  leaving  only  eight,*  3.5  per  cent  of  the  total,  unheard 
from  at  the  close  of  the  canvass.  Further  correspondence  was 
necessary  because  a  considerable  number  of  the  replies  were  in- 
complete in  some  particular,  and  in  the  end  it  was  not  possible 
to  secure  complete  information  on  all  points  from  all  the  219 

TABLE    I. — NUMBER  OF  CITIES  OF  25,000  POPULATION  AND  OVER 
IN     1910     BY     STATES    AND     STATE-GROUPS 


New  England  States 

40 

West  North  Central  States 

Maine 

2 

Minnesota 

3 

New  Hampshire 

2 

Iowa 

8 

Massachusetts 

25 

Nebraska 

3 

Rhode  Island 

4 

Missouri 

5 

Connecticut 

7 

Kansas 

3 

Middle  Atlantic  States 

55 

East  South  Central  States 

New  York 

21 

Kentucky 

4 

New  Jersey 

H 

Tennessee 

4 

Pennsylvania 

20 

Alabama 

3 

South  Atlantic  States 

20 

West  South  Central  States 

Delaware 

1 

Arkansas 

1 

Maryland 

1 

Oklahoma 

2 

District  of  Columbia 

1 

Louisiana 

2 

Virginia 

5 

Texas 

8 

West  Virginia 

2 

North  Carolina 

2 

South  Carolina 

2 

Mountain  States 

6 

Georgia 

4 

Montana 

1 

Florida 

2 

Colorado 
Utah 

3 
2 

East  North  Central  States 

48 

Pacific  States 

Michigan 

9 

Washington 

3 

Wisconsin 

8 

Oregon 

1 

Ohio 

14 

California 

8 

Indiana 

5 

Illinois 

12 

13 


Total  227 


cities  reporting.  The  smallest  number  of  cities  giving  satis- 
factory information  in  answer  to  any  one  of  the  questions  regard- 
ing the  department's  program  was  201 — in  the  case  of  the  ques- 
tion regarding  infant  mortality. 

The  fiscal  year  for  which  information  from  the  majority  of  the 

♦Columbia,    S.    C;  Council    Bluffs,    la.;  Holyoke,    Mass.;  Joplin,    Mo. 
Knoxville,  Tenn.;  Newport,  Ky.;  Springfield,  Mo.;  Waco,  Tex. 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 

cities  was  secured  is  the  calendar  year  of  1913;  in  a  few  cases  it 
varied  slightly  from  this  period  and  in  a  few  cases  the  appro- 
priation figure  for  191 2  had  to  be  accepted.  Such  cases  were, 
however,  relatively  rare  and  occurred  in  such  distribution  as  not 
to  vitiate  any  of  the  conclusions  presented  in  this  paper.  The 
populations  used  in  all  computations  are  those  for  July  1,  1913, 
as  estimated  by  the  Bureau  of  the  Census.  While  absolute 
accuracy  cannot  be  claimed  for  the  material  contained  in  this 
paper,  no  effort  has  been  spared  to  draw  only  conclusions  for 
which  the  data  is  adequate,  and  it  is  confidently  believed  that  the 
picture  presented  is  a  fair  representation  of  conditions  existing 
at  the  time  of  the  investigation. 

Appropriation 

The  first  inquiry  on  the  schedule  related  to  the  amount  of  the 
department's  annual  appropriation.  This  question  was  answered 
by  206  cities,  representing  a  population  of  29,488,321 ;  the  aggre- 
gate total  appropriation  being  $13,155,547,  giving  a  crude  per 
capita  figure  of  44.6  cents.  As  this  figure  was  sure  to  include 
many  expenditures  not  common  to  all  departments,  and  many 
of  no  special  hygienic  significance,  a  second  question  inquired 
what  parts  of  the  crude  appropriation  should  be  charged  off  for 
the  following  enterprises:  hospitals  and  sanitoria;  plumbing 
inspection;  street  cleaning;  the  removal  or  disposal  of  dead 
animals,  refuse,  garbage,  or  night  soil;  and  any  other  unusual 
undertakings.  Deducting  these  items,  the  remaining  expenditure 
should  represent  with  considerable  accuracy  the  amount  devoted 
to  actual  preventive  measures,  and  should  offer  a  fair  basis  for 
comparison  between  cities  of  different  size  and  location.  This 
corrected  figure,  which  is  the  one  discussed  in  this  paper  except 
where  specifically  stated  to  the  contrary,  aggregated  $9,650,515, 
or  32.7  cents  per  capita.  Excluding  New  York  City,  with  its 
big  appropriation  of  over  three  million  dollars,  the  figure  drops 
to  27.3  cents  per  capita.  The  facts  regarding  these  appropria- 
tion figures  for  the  grand  divisions  of  states  are  shown  in  Table  2. 

The  general  tendency  of  the  per  capita  appropriation  to  vary 
directly  with  the  size  of  the  city  is  shown  in  Table  3,  which  gives 
both  the  aggregate  per  capita — obtained  by  dividing  the  aggre- 

5 


ACTIVITIES   OF  MUNICIPAL   HEALTH  DEPARTMENTS   IN   U.    S. 

gate  appropriation  by  the  aggregate  population,  and  the  average 
of  the  per  capita  figures  of  the  individual  cities. 

TABLE   2. — POPULATIONS   AND   HEALTH   DEPARTMENT   APPROPRIA- 
TIONS OF  CITIES  BY  STATE-GROUPS 


Cities 
report- 
ing 

Aggregate 
population 

Appropriation 

Group  of 
States 

Total 
amount 

"  Cor- 
rected" 
amount 

Ratio  of 

"cor-  i 

rected" 

to  total 

New  England 

Middle  Atlantic .... 

South  Atlantic 

East  North  Central .  . 
West  North  Central. 
East  South  Central .  . 
West  South  Central . 
Mountain 

39 

55 
17 
44 
17 
8 

9 

5 

12 

3,344,302 

11,541,623 

1,853,087 

6,716,947 

1,850,371 

852,073 

838,263 

462,943 
2,028,712 

$1,585,486 

5,846,815 

785,704 

2,141,899 

467,428 

329,720 

299,025 

307,262 

1,392,208 

$938,775 
4,716,305 
601,280 
1,655,739 
358,381 
267,440 
230,187 
164,203 
718,205 

59-2% 
80.7 

76.5 
77-3 
76.7 
81. 1 
77.0 
53-4 
51.6 

Pacific 

Total 

206 

29,488,321 

$13,155,547 

$9,650,515 

73-4% 

TABLE    3. — HEALTH    DEPARTMENT    APPROPRIATIONS a   PER    CAPITA 
IN   CITIES   BY   SIZE-GROUPS 


Cities  having 
population  of 

Cities 
report- 
ing 

Aggregate 
population 

Aggregate 
appropri- 
ation 

Aggre- 
gate per 
capita 

Aver- 
age per 
capita 

Aver- 
age pop- 
ulation 

300,000  and  over. 

300,000   and   over 

excluding  New 

York  City 

100,000  to  300,000 

50,000  to  100,000 

25,000  to    50,000 

17 

16 
38 
55 
96 

16,087,038 

10,888,150 

6,045,943 
3,890,259 
3,465,081 

$6,486,979 

3,477,033 

1,688,959 

790,014 

684,563 

40.3c 

31-9 
27.9 
20.3 
19.8 

34.0c 

32.6 
26.7 
19.6 
19-3 

946,296 

680,509 

159,104 

70,732 

36,095 

All  cities 

206 

29,488,321 

$9,650,515 

32.7c 

21.9c 

H3,H7 

All    cities    exclud- 
ing   New    York 
City 

205 

24,289,433 

$6,640,569 

27.3c 

21. 8c 

118,485 

a  "Corrected"  appropriation 

The  largest  corrected  figure  was  that  of  Seattle — $.98;    the 

6 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 

smallest  that  of  Clinton,  Iowa, — three  fourths  of  one  cent. 
Others  of  the  larger  expenditures  were  Memphis,  Tenn.,  $.93, 
Pittsburgh,  Pa.,  $.61,  Augusta,  Ga.,  $.61,  and  New  York  City, 
$.58;  among  the  smaller  were  Easton,  Pa.,  $.02,  Aurora,  111., 
and  South  Bend,  Ind.,  $.03,  Woonsocket,  R.  I.,  $.04,  and  Lewis- 
ton,  Me.,  $.06.  Such  ridiculously  small  appropriations  are  by 
no  means  rare,  and  are  to  be  found  in  almost  any  part  of  the 
country.  The  variation  in  liberality  of  the  different  sections 
of  the  country  is  brought  out  in  Table  4,  which  shows  the  average 
per  capita  figure  for  the  cities  in  the  principal  groups  of  states. 

TABLE  4. — HEALTH  DEPARTMENT  APPROPRIATIONS  a  PER  CAPITA  IN 
CITIES  BY  STATE-GROUPS 


Group  of 
states 


New  England 

Middle  Atlantic 

South  Atlantic 

East  North  Central . 
West  North  Central . 
East  South  Central  . 
West  South  Central . 

Mountain 

Pacific 


Total . 


206 


Cities 

Average 

Average 

reporting 

population 

per  capita 

39 

85,751 

24.0c 

55 

209,848 

19.0 

17 

109,005 

34-4 

44 

152,658 

15-2 

17 

108,845 

15-4 

8 

106,509 

32.2 

9 

93,HO 

28.7 

5 

92,589 

29.8 

12 

169,059 

29.7 

143,147 


21.9c 


a  "Corrected"  appropriation 

It  is  evident  that  marked  variations  occur,  and  that  these  are 
out  of  all  proportion  to  differences  in  size  of  the  cities  in  the  sev- 
eral groups  of  states.  Relatively  the  largest  appropriations  are 
in  the  southeastern  states;  the  smallest  in  the  north  central. 
That  these  differences  are  of  real  significance  with  regard  to  the 
strength  of  the  health  departments  in  different  parts  of  the  coun- 
try will  become  clearer  in  the  light  of  the  results  of  the  other 
parts  of  the  present  investigation. 


Infant  Mortality 
The  third  question  on  the  schedule  related  to  the  department's 
efforts  against  infant  mortality.     Of  201  cities  furnishing  definite 

7 


ACTIVITIES   OF   MUNICIPAL  HEALTH  DEPARTMENTS  IN   U.    S. 

replies,  137,  or  68.2  per  cent,  attempted  milk  inspection;  89  of 
these  also  employed  nurses  or  maintained  baby  welfare  stations ; 
while  17  relied  solely  on  private  agencies.  Forty-four  per  cent 
of  the  cities,  in  other  words,  possessed  the  essential  features  of  a 
program  for  the  prevention  of  the  avoidable  deaths  of  the  new- 
born and  very  young;  8.5  per  cent  relied  for  such  work  solely  on 
private  agencies;  while  in  45  cities,  or  22  per  cent  of  the  whole, 
no  effort  whatever  was  made,  not  even  milk  inspection. 

TABLE    5. INFANT    HYGIENE    WORK    IN    CITIES    BY    SIZE-GROUPS 


Cities  having 
population  of 

Cities 
report- 
ing 

Having  "complete"  program 

Making  no  effort 

Number 

Per  cent 

Number 

Per  cent 

300,000  and  over.  . 
100,000  to  300,000 . 

50,000  to  100,000. 

25,000  to    50,000. 

18 
39 
50 
94 

17 
27 
21 

24 

94-4 
69.2 
42.0 
25-5 

0 

3 
11 

3i 

0.0 

7-7 
22.0 
33-o 

All  cities 

201 

89 

44-3 

45 

22.4 

The  variations  in  the  amount  of  interest  shown  in  the  saving 
of  infant  life  by  cities  of  different  size  are  brought  out  in  Table  5. 
It  is  plainly  evident  that  the  smaller  cities  are  very  neglectful 
in  this  regard;    whereas  94  per  cent  of  the  cities  over  300,000 


TABLE    6. INFANT    HYGIENE    WORK   IN    CITIES    BY    STATE-GROUPS 


Group  of 
states 

Cities 
reporting 

Average 
population 

Having  "  complete  "  program 

Number 

Per  cent 

New  England 

35 
53 
17 
46 
18 

7 
11 

5 
9 

89,283 

215,615 
112,298 
H7,205 

121,325 

113,482 

91,237 

92,589 

203,442 

21 
21 

7 
16 

7 
4 
6 
2 
5 

60.0 

Middle  Atlantic 

South  Atlantic 

East  North  Central .... 
West  North  Central .... 
East  South  Central .... 
West  South  Central .... 
Mountain 

39-6 
41.2 
34-8 
38.9 
57-i 
54-5 
40.0 

55-6 

Total 

201 

146,809 

89 

44-3 

ACTIVITIES   OF  MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

population  had  what  may  be  called  a  complete  program — milk 
inspection,  and  nurses  and  infant  welfare  stations  to  follow  up 
births  and  educate  mothers,  only  26  per  cent  of  the  cities  between 
25,000  and  50,000  had  initiated  such  work.  Similarly  not  one 
of  the  first-named  group  of  cities  failed  to  do  something;  while 
33  per  cent  of  the  smaller  ones  did  nothing  whatever. 

Table  6  brings  out  the  differences  in  the  activity  with  respect 
to  this  kind  of  work  of  health  departments  in  different  parts  of 
the  country.  Here  again  it  is  interesting  to  note  that  the  poorest 
showings  are  made  by  the  North  Central  states,  with  New 
England  and  the  South  Central  and  Pacific  states  in  the  leading 
positions. 

Medical  Inspection  of  School  Children 
The  fourth  question,  on  medical  inspection  of  school  children, 
was  in  most  cases  easily  and  clearly  answered.  Of  211  cities 
reporting,  167,  or  79  per  cent,  reported  some  such  inspection; 
the  work  being  in  103  instances  under  the  school  authorities  as 
against  56  for  the  health  department.  Five  cities  reported  the 
inspection  in  public  schools  under  the  school  authorities  with 
that  in  parochial  or  private  schools  under  the  health  department, 
while  three  reported  joint  control  by  the  two  authorities. 


TABLE  7. — MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN  IN  CITIES 

BY    SIZE-GROUPS 


Cities  having 
population  of 

Cities 
reporting 

Having  inspection 

Number 

Per  cent 

300,000  and  over 

100,000  to  300,000 

50,000  to  100,000 

18 

39 

52 

102 

18 

37 
40 

72 

100.0 

94-9 
76.9 

25,000  to    50,000 

70.6 

All  cities 

211 

167 

79.1 

Again  the  big  cities  lead,  as  is  shown  in  Table  7,  although  in 
this  case  the  showing  of  the  smaller  cities  is  better  than  in  the 
case  of  infant  hygiene  work.  All  of  the  larger  cities  had  inspec- 
tion systems,  while  even  71  per  cent  of  the  group  of  smallest  cities 

9 


ACTIVITIES   OF   MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

provided  the  service.  The  examination  of  school  children  is 
evidently  one  of  the  features  of  a  public  health  program  whose 
importance  has  something  like  general  recognition. 


table  8. 


-MEDICAL  INSPECTION  OF  SCHOOL  CHILDREN  IN  CITIES 
BY  STATE  GROUPS 


Group  of 
states 


New  England 

Middle  Atlantic 

South  Atlantic 

East  North  Central. 
West  North  Central 
East  South  Central . 
West  South  Central 

Mountain 

Pacific 

Total 


Cities 

Average 

reporting 

population 

37 

87,129 

53 

215,097 

19 

104,780 

47 

144.739 

19 

129,357 

9 

98,890 

IO 

87,361 

5 

92,589 

12 

169,059 

211 

142,799 

Having  inspection 


Number 


37 
49 
12 
29 
12 


1 
11 


167 


Per  cent 


1 00.0 

92.5 
63.2 
61.7 
63.2 
88.9 
80.0 
20.0 
91.7 


79-i 


It  is  interesting  to  note  that  the  provision  for  inspection  is 
most  complete  in  the  New  England  and  Middle  Atlantic  states, 
with  the  Pacific  and  South  Central  states  following.  The 
Mountain  group  is  markedly  the  poorest  off,  while  the  showing 
of  the  North  Central  states  is  again  relatively  inferior. 


Laboratory  Service 

The  fifth  question  related  to  the  department's  laboratory 
facilities.  The  commoner  laboratory  diagnoses — for  diphtheria, 
tuberculosis,  and  typhoid,  were  offered  in  136,  or  62  per  cent  of 
the  218  cities  reporting.  Of  the  other  diseases  gonorrhea  was 
fairly  often  included,  but  syphilis  less  frequently.  The  replies 
regarding  the  examination  of  water,  milk,  and  foods,  showed  that 
nearly  three-fourths  of  the  departments  had  facilities  for  chemical 
and  bacteriological  determinations. 

Once  again  the  larger  cities  make  the  better  showings,  as  may 
be  seen  from  Table  9.  In  the  group  of  largest  cities  all  have 
well-rounded  laboratories.  Among  the  smaller  cities  it  is  inter- 
esting to  note  that  their  weakness  is  more  pronounced  with  regard 

10 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 

TABLE  9. HEALTH  DEPARTMENT  LABORATORY  SERVICE  IN  CITIES 

BY  SIZE-GROUPS 


Cities  having 

Cities 
report- 
ing 

Having 

diagnostic 

service 

Having  bac- 
teriological 
service 

Having 

chemical 

service 

population  of 

Num- 
ber 

Per 
cent 

Num- 
ber 

Per 

cent 

Num- 
ber 

Per 

cent 

300,000  and  over 
100,000  to  300,000 
50,000  to  100,000 
25,000  to    50,000 

18 
40 

57 
103 

218 

18 
33 
34 
5i 

100. 0 
82.5 
59-6 
49-5 

62.4 

18 

33 
42 
62 

100.0 

82.5 

73-7 
60.2 

18 
36 
39 
63 

156 

100.0 
90.0 
68.4 
61.2 

All  cities 

136 

155 

71. 1 

71.6 

to  facilities  for  laboratory  diagnosis  of  communicable  diseases 
than  those  for  chemical  and  bacteriological  examination  of  milk, 
water,  and  food,  a  circumstance  which  must  be  regarded  as  un- 
fortunate. 


table  10.- 


-HEALTH  DEPARTMENT  LABORATORY  SERVICE  IN  CITIES 
BY  STATE-GROUPS 


Having 

Havin 

gbac- 

Having 

Group  of 

Cities 
report- 

Average 
popula- 

diagnostic 
service 

teriological 
service 

chemical 
service 

states 

ing 

tion 

Num- 

Per 

Num- 

Per 

Num- 

Per 

ber 

cent 

ber 

cent 

ber 

cent 

New  England 

39 

85,751 

24 

61.5 

28 

71.8 

27 

69.2 

Middle  Atlantic 

55 

209,848 

31 

56.4 

33 

60.0 

32 

58.2 

South  Atlantic 

19 

104,780 

16 

84.2 

16 

84.2 

15 

78.9 

East  North  Cen- 

tral 

48 

143,020 

26 

54-2 

34 

70.8 

35 

72.9 

West    North 

Central 

19 

129,357 

10 

52.6 

13 

68.4 

14 

73-7 

East  South 

Central 

9 

98,890 

8 

88.9 

9 

100.0 

9 

100.0 

West  South 

Central 

12 

89,226 

8 

66.7 

9 

75-o 

9 

75-o 

Mountain 

5 

92,589 

2 

40.0 

2 

40.0 

4 

80.0 

Pacific 

12 

169,059 
140,605 

11 

91.7 
62.4 

11 

91.7 
71. 1 

11 

91.7 

Total 

218 

136 

155 

156 

71.6 

Table  10  shows  the  varying  strength  of  health  department 
laboratory  service  in  the  different  parts  of  the  country.     The 

11 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN   U.    S. 

South  Eastern  and  Pacific  states  again  make  superior  showings, 
while  the  Middle  Atlantic,  North  Central,  and  Mountain  states 
show  perhaps  the  greatest  opportunities  for  improvement. 


Publicity  and  Education 
Passing  to  efforts  at  health  education  and  publicity,  over  one- 
fourth  of  214  departments  reported  no  effort  whatever.  The 
favorite  medium  for  such  endeavors  when  made  was  the  news- 
paper, utilized  to  some  degree  or  other  in  88  instances.  Fifty- 
three,  or  one-fourth,  of  the  departments  issued  regular  bulletins; 
56  attempted  lectures;  while  51  distributed  pamphlets  or  circu- 
lars. Table  11,  giving  the  number  and  proportion  of  depart- 
ments having,  on  the  one  hand,  regular  bulletins  and,  on  the 
other,  doing  nothing  at  all,  gives  an  idea  of  the  variation  in  value 
of  efforts  in  this  line  by  cities  of  different  size. 

TABLE     II. TWO    TESTS    OF    HEALTH    DEPARTMENT    EFFORTS    AT 

HEALTH  EDUCATION  AND  PUBLICITY  IN  CITIES  BY  SIZE-GROUPS 


Cities  having 

Cities 
report- 
ing 

Having  regular 
bulletins 

Making  no  effort 

population  of 

Num- 
ber 

Per 

cent 

Num- 
ber 

Per 

cent 

300,000  and  over 
100,000  to  300,000 
50,000  to  100,000 
25,000  to    50,000 

18 
40 

54 
102 

13 

13 

9 

18 

72.2 

32.5 
16.7 
17.6 

0 

9 

13 

37 

0.0 
22.5 
24.1 

36.3 

All  cities 

214 

53 

24.8 

59 

27.6 

The  story  told  is  again  the  same;  the  larger  cities  have  a 
higher  percentage  of  regular  bulletins  and  a  lower  percentage  of 
departments  making  no  effort.  The  indications  with  regard  to 
the  regular  bulletin  corresponds  in  a  general  way  to  those  for 
other  forms  of  publicity  and  education;  cities  having  bulletins 
are  more  likely  to  carry  on  the  other  activities. 

The  Pacific  states  lead  in  the  two  tests  applied  in  Table  12, 
followed  by  the  East  South  Central  states.  The  Mountain 
states  and  New  England  are  much  in  the  rear;  while  the  North 
Central  states  this  time  hold  an  intermediate  position.     Con- 

12 


ACTIVITIES   OF  MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

TABLE    12. — TWO    TESTS    OF    HEALTH    DEPARTMENT    EFFORTS    AT 
HEALTH    EDUCATION    AND    PUBLICITY    IN    CITIES    BY    STATE- 
GROUPS 


Having 

regular 

Making  no 

Group  of  states 

Cities 

Average 
popula- 

bulletins 

effort 

report- 

ing 

tion 

Num- 

Per 

Num- 

Per 

ber 

cent 

ber 

cent 

New  England 

38 

86,907 

7 

18.4 

16 

42.1 

Middle  Atlantic 

54 

212,784 

11 

20.4 

17 

3i-5 

South  Atlantic 

18 

106,853 

5 

27.8 

6 

33-3 

East  North  Central 

48 

143,020 

10 

20.8 

9 

18.8 

West  North  Central 

19 

129,357 

6 

31-6 

4 

21. 1 

East  South  Central 

9 

98,890 

3 

33-3 

1 

11. 1 

West  South  Central 

11 

89,181 

3 

27-3 

1 

9-i 

Mountain 

5 

92,589 

1 

20.0 

4 

80.0 

Pacific 

12 

169,059 
142,063 

7 

58.3 

1 

8-3 

Total 

214 

53 

24.8 

59 

27.6 

siderable  progress  probably  has  been  made  in  health  department 
educational  effort  since  the  time  this  investigation  was  initiated, 
as  this  field  is  one  of  the  more  rapidly  developing  ones  of  health 
work;  but  certainly  the  opportunity  for  improvement  existed 
throughout  the  country  and  on  a  large  scale. 


Venereal  Diseases 
Some  interesting  replies  were  received  to  the  question  as  to 
what  steps  the  department  had  taken  toward  control  of  the  ve- 
nereal diseases.  Twenty-eight  cities  reported  some  effort  more 
aggressive  than  free  laboratory  diagnosis.  In  fourteen  cities 
the  problem  was  attacked  along  the  line  of  case  reporting ;  seven 
requiring  reports,  five  requesting  them,  two  requiring  them  from 
institutions,  and  one  making  free  laboratory  diagnosis  conditional 
on  report  of  the  case.  Another  line  of  attack  was  represented  by 
the  free  laboratory  diagnosis  of  gonorrhea  and  syphilis — the 
former  being  offered  in  82  cities,  the  latter  in  46.  Four  cities 
offered  free  dispensary  treatment;  three  forced  dangerous  cases 
into  hospitals;  and  two  offered  hospital  care  to  indigents.  Regu- 
lar inspections  of  prostitutes  were  made  in  eight  cities — this  type 
of  effort  in  most  instances  being  commented  on  as  unsatisfactory 

13 


ACTIVITIES   OF  MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

in  results.  Publicity  and  education,  reported  by  three  cities; 
placarding  of  houses  of  prostitution  when  considered  necessary, 
reported  by  one  city;  and  prohibition  of  employment  of  persons 
having  venereal  disease  in  food-handling  places,  also  reported  by 
one  city ;  completes  a  list  of  measures  attempted  which  probably 
indicates  certain  of  the  ways  in  which  health  departments  will 
endeavor  to  combat  these  highly  important  diseases  in  the  future. 

Dispensaries  and  Outdoor  Relief 
The  replies  to  the  question  relating  to  the  existence  of  city 
dispensaries  and  outdoor  relief  are  worth  analysis  because  of  the 
opportunities  possession  of  such  service  offers  the  health  depart- 
ment in  the  way  of  locating  and  controlling  otherwise  undis- 
covered sources  of  infectious  disease.  Sixty-six  of  211  cities 
reported  a  free  dispensary  service ;  administration  being  in  charge 
of  the  health  department  in  22  instances,  the  charity  department 
in  18,  city  hospital  in  10,  a  private  organization  receiving  a  city 
subsidy  in  seven,  the  county  in  six,  and  the  police  department  in 
three  instances.  Fourteen  cities  reported  district  physicians 
working  under  the  direction  of  the  health  department. 

TABLE  13. — REPORTS  OF  FREE  DISPENSARY  SERVICE  IN  CITIES  BY 

SIZE-GROUPS 


Cities 
reporting 

Having  service 

Cities  having  population  of 

Number 

Per  cent 

300,000  and  over 
100,000  to  300,000 
50,000  to  100,000 
25,000  to    50,000 

18 
38 
54 

IOI 

11 
19 
13 
23 

61. 1 
50.0 
24.1 
22.8 

All  cities 

211 

66 

3i-3 

Table  13  makes  it  clear  that  the  larger  cities  reported  a  mark- 
edly higher  proportion  of  free  dispensaries;  while  Table  14  shows 
the  relative  frequency  of  this  service  in  different  parts  of  the 
country.  The  Southern  states  again  make  the  best  showings; 
the  North  Central  and  Mountain  states  the  poorest. 

14 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 


TABLE    14. REPORTS    OF    FREE    DISPENSARY    SERVICE    IN    CITIES 

BY  STATE-GROUPS 


Group  of  states 

Cities 
reporting 

Average 
population 

Having  service 

Number 

Per  cent 

New  England 
Middle  Atlantic 
South  Atlantic 
East  North  Central 
West  North  Central 
East  South  Central 
West  South  Central 
Mountain 
Pacific 

39 

53 
19 
47 
18 

9 

9 

5 

12 

85,751 
215,611 
104,780 
145,066 

121,325 
98,890 

93,542 

92,589 

169,059 

142,123 

14 
16 
8 
11 
4 
4 
5 
1 

3 

35-9 
30.2 
42.1 

23-4 
22.2 
44.4 
55-6 
20.0 
25.0 

Total 

211 

66 

31.3 

Tuberculosis 

Surely  in  these  days  one  would  expect  the  doctrine  of  tubercu- 
losis prevention  to  be  widely  spread,  yet  only  23.9  per  cent  of  the 
cities  reported  a  comprehensive  program;  6.2  per  cent  fell  a 
little  short  of  such  a  program;  14.4  per  cent  reported  no  attempt 
whatever;  while  55.5  per  cent*  were  satisfied  with  mere  frag- 
ments of  a  program.  The  phrase  "comprehensive  program"  is 
used  here  to  include  compulsory  reporting  of  cases,  free  laboratory 
diagnosis,  investigation  and  visitation  of  reported  cases  by  nurses 
or  medical  inspectors,  free  sanatorium  facilities  for  those  who 
need  them,  and  disinfection  after  the  termination  or  removal  of 
a  case. 

The  variation  in  amount  and  value  of  anti-tuberculosis  work 
in  cities  of  different  size  is  very  striking,  as  may  be  seen  from 
Table  15.  Whereas  78  per  cent  of  the  cities  over  300,000  popula- 
tion had  comprehensive  programs,  only  12  per  cent  of  the  cities 
between  25,000  and  50,000  enter  this  class.  Similarly,  only  11 
per  cent  of  the  larger  cities  fail  to  investigate  the  reported  cases, 
as  compared  with  77  per  cent  for  the  smaller  cities.  Finally, 
none  of  the  larger  cities  ignores  the  problem  entirely  as  compared 
with  nearly  a  fifth  of  the  smaller  cities  which  made  no  effort 
whatever. 

*  Includes  6.7  per  cent  on  account  of  Pennsylvania  cities  reporting  state 
dispensary  system. 

15 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 


TABLE    15. 


-HEALTH    DEPARTMENT    TUBERCULOSIS    PROGRAMS    IN 
CITIES  BY  SIZE-GROUPS 


Cities  having 
population  of 

Cities 
report- 
ing 

Having 
"compre- 
hensive" 
program 

No  case 

investiga- 
tion 

No  activity 
whatever 

Num- 
ber 

Per 
cent 

Num- 
ber 

Per 

cent 

Num- 
ber 

Per 

cent 

300,000  and  over 
100,000  to  300,000 
50,000  to  100,000 
25,000  to    50,000 

18 
37 
56 
98 

14 

16 

8 

12 

77-8 
43-2 
14-3 
12.2 

2 

18 
37 
75 

132 

11. 1 

48.6 
66.1 
76.5 

63.2 

0 

4 

8 

18 

0.0 
10.8 

14-3 
18.4 

All  cities 

209 

50 

23-9 

30 

14.4 

TABLE    l6. HEALTH    DEPARTMENT    TUBERCULOSIS    PROGRAMS    IN 

CITIES    BY    STATE-GROUPS 


Having 
prehei 

"com- 

No  case  in- 

No activity 

Cities 

Average 

lsive 

vestigation 

whatever 

Group  of  states 

report- 
ing 

popula- 
tion 

program 

Num- 

Per 

Num- 

Per 

Num- 

Per 

ber 

cent 

ber 

cent 

ber 

cent 

New  England 

38 

87,268 

14 

36.8 

22 

57-9 

5 

13.2 

Middle  Atlantic 

53 

215,610 

13 

24-5 

21 

39-6 

3 

5-7 

South  Atlantic 

18 

108,574 

5 

27.8 

12 

66.7 

4 

22.2 

East  North 

Central 

48 

143,020 

11 

22.9 

36 

75-0 

8 

16.7 

West  North 

Central 

17 

126,155 

2 

11.8 

13 

76.5 

4 

23-5 

East  South 

Central 

8 

91,451 

3 

37-5 

5 

62.5 

1 

12.5 

West  South 

Central 

10 

93J59 

0 

00.0 

10 

1 00.0 

3 

30.0 

Mountain 

5 

92,589 

0 

00.0 

5 

100.0 

2 

40.0 

Pacific 

12 

169,059 
142,883 

2 

16.7 

8 

66.7 

0 

00.0 

Total 

209 

5o 

23-9 

132 

63.2 

30 

14.4 

In  the  regional  analysis,  given  in  Table  16,  the  West  South 
Central  and  Mountain  cities  make  the  poorest  showings  of  all, 
none  of  these  reporting  a  comprehensive  program  and  none  in- 
vestigation of  reported  cases.  These  regions  also  furnish  the 
highest  proportions  of  cities  absolutely  ignoring  the  problem. 

16 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 

The  showings  of  the  eastern  cities  are  manifestly  the  better,  and 
probably  reflect  the  extent  and  energy  of  the  anti-tuberculosis 
campaigns  carried  on  by  private  organizations  in  these  districts. 

Other  Hygienic  Considerations 
Another  branch  of  public  hygiene  receiving  little  attention  in 
these  cities  is  that  relating  to  industry.  Out  of  217  cities,  only 
11,  or  5.1  per  cent,  reported  any  effort.  Four  of  these  reported 
inspection  systems;  others  reported  lectures  and  bulletins,  and 
co-operative  efforts  with  labor  unions.  The  larger  cities  re- 
ported a  higher  proportion  of  endeavor,  the  proportion  ranging 
from  27.8  per  cent  for  the  cities  of  300,000  population  and  over 
down  to  one  per  cent  for  cities  of  25,000  to  50,000.  The  number 
of  cities  answering  this  question  in  the  affirmative  was  too  small 
to  make  their  regional  distribution  of  any  significance.  In 
considering  the  slight  interest  shown  by  our  cities  in  industrial 
hygiene  it  must  be  remembered  that  this  work  is  often,  and  prop- 
erly, delegated  to  the  state  industrial  authorities;  still  it  cannot 
be  denied  that  with  the  present  development  of  state  effort  there 
is  ample  opportunity  for  useful  activity  on  the  part  of  local  health 
authorities. 

Another  subject  on  which  information  was  solicited  was  the 
existence  of  a  "housing"  code  as  distinguished  from  a  "building" 
code.  Of  209  cities  153  answered  this  question  in  the  negative. 
The  proportion  of  cities  reported  as  having  no  regulations  ranged 
from  22.2  per  cent  for  cities  over  300,000  population  up  to  86.1 
per  cent  for  cities  between  25,000  and  50,000.  The  Pacific  cities 
reported  the  highest  proportion  of  regulations;  the  Mountain 
cities  the  lowest. 

The  approximate  number  of  dry  closets  and  privy  vaults, 
although  not  a  direct  test  of  the  status  of  the  health  department's 
program,  was  considered  of  enough  importance  to  justify  the 
insertion  of  an  inquiry  on  the  questionaire.  Of  the  total  of  219 
departments  heard  from  during  the  entire  investigation  25.6 
per  cent  were  unable  to  give  even  an  approximate  answer  to  this 
question.  The  aggregate  population  of  the  163  cities  that  did 
furnish  estimates  was  25,595,415,  the  aggregate  number  of  privies 
being  479,947,  giving  a  ratio  of  18.8  privies  per  1,000  population. 

17 


ACTIVITIES   OF  MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

The  average  of  the  privies  per  1,000  population  ratios  of  all  these 
cities  was  somewhat  higher — 33.8.  In  connection  with  these 
estimates  the  writer  would  draw  attention  to  the  fact  that  in  his 
experience  such  estimates  by  local  authorities  of  the  number  of 
wells  and  privies  in  their  city  err  greatly  on  the  side  of  under- 
statement. From  the  figures  in  hand  it  is  probably  in  no  wise 
extravagant  to  estimate  a  total  of  a  million  privies  in  our  cities. 


table  17.- 


-PRIVIES  AS  ESTIMATED  BY  THE  HEALTH  AUTHORITIES 
IN   CITIES   BY   SIZE-GROUPS 


Cities  having  population  of 

Cities 
reporting 

Number 
of  privies 

Average  of 
per  1,000 
population 

300,000  and  over 
100,000  to  300,000 
50,000  to  100,000 
25,000  to    50,000 

15 
31 

43 
74 

146,904 

139,416 

90,889 

102,738 

15-3 

3i-3 
3i-i 

40.2 

All  cities 

163 

479,947 

33-8 

A  glance  at  Table  17  makes  it  appear  that  the  small  cities  are 
again  relatively  the  worst.  The  large  number  of  privies  in  the 
larger  cities,  however,  shows  that  the  country's  privy  problem  is 
not  restricted  to  the  smaller  cities. 


table  18.- 


-PRIVIES   AS   ESTIMATED    BY   HEALTH   AUTHORITIES    IN 
CITIES  BY  STATE-GROUPS 


Group  of  states 

Cities 

reporting 

Average 

population 

Number    1  fAver5*L 
r      •   •       101  per  1,000 
01  privies             1  I- 
v             1  population 

New  England 
Middle  Atlantic 
South  Atlantic 
East  North  Central 
West  North  Central 
East  South  Central 
West  South  Central 
Mountain 
Pacific 

29 
42 
16 
36 
15 
8 
6 

3 

8 

73,522 
252,638 
H5,297 
175,975 
137,134 
97,023 
60,071 
124,063 
138,345 

8,566 
114,812 

47,385 

142,100 

64,390 

43,094 
21,500 
19,000 
19,100 

5-9 
24.7 

5i. 1 
48.3 
30.4 
77-4 
55-9 
63.0 

18.5 

Total 

163 

157,027 

479,947 

33-8 

16 


ACTIVITIES   OF  MUNICIPAL  HEALTH  DEPARTMENTS   IN   U.    S. 

In  the  regional  analysis  New  England  appears  far  and  away 
ahead,  with  the  Pacific  and  Middle  Atlantic  states  following. 
The  Southern  and  Mountain  cities  have  relatively  the  greatest 
number  of  privies,  with  the  North  Central  states  in  an  inter- 
mediate position. 

Summary  and  Conclusions 

What  now  are  the  conclusions  to  be  drawn  from  these  figures? 
We  have  seen  that  at  the  time  of  this  investigation  a  fifth  of  the 
cities  made  no  inspection  of  school  children;  over  a  third  did  not 
offer  the  ordinary  laboratory  diagnosis  for  the  commoner  com- 
municable diseases;  over  a  fourth  made  no  effort  to  educate  in 
health  matters;  nearly  three-fourths  had  no  housing  law;  nine- 
teen-twentieths  had  no  concern  with  the  hygiene  of  industry; 
over  six-sevenths  had  no  program  against  the  venereal  diseases; 
over  a  half  had  no  proper  organization  to  combat  infant  mortal- 
ity; and  less  than  a  quarter  had  a  coherent  program  against 
tuberculosis.  Surely  these  facts  argue  for  a  surprising  amount  of 
neglected  opportunity.  And  when  we  consider  that  this  investi- 
gation made  no  effort  to  determine  the  efficiency  of  the  work 
attempted,  but  only  whether  or  not  it  was  attempted ;  and  when, 
with  the  departments  with  which  we  are  familiar  in  mind,  we 
reflect  on  the  partial  thoroughness  with  which  their  slender  staffs 
compel  them  to  perform  their  work,  the  conclusion  becomes  in- 
evitable that  public  health  work  in  this  country  is  still  in  its 
infancy — certainly  as  far  as  application  of  established  scientific 
methods  is  concerned. 

The  striking  correlation  between  the  size  of  the  city  and  the 
activity  of  the  health  department  is  another  important  result. 
Figure  2,  which  presents  graphically  the  rankings  with  regard  to 
the  several  subjects  of  investigation  of  the  groups  of  different  sized 
cities,  shows  that  in  every  case  the  larger  cities  made  the  better 
showings,  receiving  relatively  more  money  from  the  public  treas- 
ury and  carrying  on  larger  and  more  intensive  programs.  It 
might  be  argued  that  this  fact  does  not  mean  a  better  meeting  of 
the  public  health  problem  by  the  larger  cities — that  conditions 
in  the  larger  cities  are  so  much  worse  that  they  are  compelled  to 
carry  on  more  extensive  health  department  work  in  order  to  keep 

19 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 


Cities  having  popu- 
lation of 


Ap- 

pro- 
pria- 
tion 


In- 

Laboratory  service 

Edu- 

Dis- 

Infant 

tionof 

cation 

pen- 

mor- 

school 

Bac- 

and 

sary 

tality 

chil- 

terio- 

pub- 

ser- 

dren 

logical 

licity 

vice 

Tu- 
bercu- 
losis 


300,000  and  over 


100 


11     11    ii — ir 


000  to  300,000 


50,000  to  100,000 


25,000  to    50,000 


Fig.  2. — Ranking  with  Regard  to  Nine  Tests  of  Health  Department 
Activity  of  Cities  by  Size-groups.  The  darker  shadings  indicate  inferior 
rankings. 


disease  down  to  the  level  existing  naturally  in  the  smaller  cities. 
Such  an  argument  is,  however,  based  entirely  on  assumption,  and 
is  in  contradiction  to  such  facts  as  that  the  rural  death  rate  of 
New  York  state  is  now  in  excess  of  that  of  New  York  City,  al- 
though the  reverse  was  formerly  the  case.  It  seems  to  the  writer 
that  the  direct  indication  is  the  more  probable  explanation  of  the 
facts;  that  is,  that  the  inhabitants  of  the  larger  cities  are  receiv- 
ing better  protection  from  preventable  disease. 

Another  striking  result  of  the  investigation  is  the  variation  in 
activity  exhibited  by  health  departments  in  different  sections 
of  the  country.  This  is  brought  out  graphically  in  Figure  3, 
which  shows  the  standing  of  each  group  of  states  with  regard  to 
each  of  the  points  of  investigation.  The  Southern  and  Pacific 
cities  clearly  out-rank  the  others;  while  the  North  Central  and 
Mountain  cities  are  markedly  inferior.  This  result  is  perhaps 
less  surprising  than  might  at  first  appear  if  we  will  reflect  on  the 
fact  that  a  good  proportion  of  our  very  best  health  officers  are 
located  in  the  South.  It  is  also  certainly  a  fact  that  many  of 
our  northern  departments,  especially  in  the  smaller  places,  are 
relics  of  other  days,  being  in  many  instances  mere  nuisance 
abatement  offices. 

One  other  point  should  receive  all  possible  emphasis — the 
relation  between  these  examples  of  municipal  neglect  and  the 
scanty  health  department  appropriations.  What  can  we  expect 
of  a  department  in  a  city  of  25,000  whose  total  appropriation  is 

20 


ACTIVITIES    OF   MUNICIPAL   HEALTH   DEPARTMENTS    IN    U.    S. 

but  $200?  And  if  the  New  York  City  department  uses  58  cents 
per  inhabitant  per  year  and  has  to  practice  great  care  to  make  it 
go  round,  what  can  our  average  city  do  on  only  22  cents?  Again, 
do  any  real  differences  in  local  conditions  require  that  Seattle 
spend  98  cents  per  inhabitant  per  year  while  Woonsocket  may 
rest  content  with  four  cents? 

The  answer  is,  of  course,  evident;  our  health  departments 
now  have  new  functions  to  perform  which  the  public  and,  it  is 
to  be  feared,  many  of  the  departments  themselves  do  not  appre- 
ciate. Far  too  many  of  our  city  health  departments  undertake 
far  too  little  in  proportion  to  their  opportunities;  on  the  other 
hand,  all  too  few  receive  an  anywhere  near  adequate  appropri- 
ation. Under  the  circumstances  one  may  re-emphasize  the  sug- 
gestion that  there  should  be  a  minimum  yearly  per  capita  figure 
for  a  modern  department — a  kind  of  minimum  wage.  The  sug- 
gestion is  not  new — having  been  made  by  Park  in  191 1,  the  figure 
set  by  him  ranging  from  50  cents  to  one  dollar  according  to  the 
size  of  the  city,  and  by  the  Committee  on  Activities  of  Municipal 
Health  Departments  of  the  American  Public  Health  Association, 


Group  of  States 


East  South  Central 


Pacific 


South  Atlantic 


West  South  Central 


New  England 


Middle  Atlantic 


East  North  Central 
West  North  Central 


Mountain 


In- 
spec- 

Laboratory  service 

Infant 

Edu- 
cation 

Dis- 
pen- 

Ap- 

pria- 

mor- 

school 

Diag- 

Bac- 

Chem- 

and 

sary 

tality 

chil- 

terio- 

ical 

pub- 

ser- 

dren 

logical 

licity 

vice 

Tu- 
bercu- 
losis 


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Fig.  3. — Ranking  with  Regard  to  Nine  Tests  of  Health  Department 
Activity  of  Cities  by  State-groups.  White  indicates  that  the  group  ranks 
among  the  highest  three;  cross-hatching  that  it  ranks  among  the  second  three; 
black  that  it  ranks  among  the  lowest  three.  The  groups  are  listed  in  the  order 
of  the  sums  of  their  rankings  with  regard  to  the  nine  tests. 


21 


ACTIVITIES   OF  MUNICIPAL  HEALTH   DEPARTMENTS   IN   U.    S. 

its  figure  being  50  cents.  Certainly  fifty  cents  for  real  preventive 
measures  would  be  an  entirely  reasonable  figure,  and  in  all  prob- 
ability the  time  is  not  far  distant  when  our  cities  will  allow  their 
health  departments  a  dollar  a  head — an  amount  still  moderate 
when  compared  with  that  spent  for  police  or  fire  protection — 
and  will  realize  a  handsome  profit  on  the  investment. 


22 


RUSSELL  SAGE  FOUNDATION  PUBLICATIONS 

The  Pittsburgh  Survey.     Six  volumes  edited  by  Paul  U.  Kellogg.     Price 
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105  EAST  22d  STREET,  NEW  YORK 


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Foundation,  New  York  City 


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